IV Tylenol vs. PO Tylenol

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justAstudent said:
Anyone know of good papers comparing the two?
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Certainly no difference in the emergent setting. As an aside, IV Tylenol has been pretty convincingly shown to cause transient hypotension.

Furyk J, Levas D, Close B, et al. Intravenous versus oral paracetamol for acute pain in adults in the emergency department setting: a prospective, double-blind, double-dummy, randomised controlled trial | Emergency Medicine Journal. Emerg Med J. 2018;35(3):179-184.

Chiam E, Weinberg L, Bailey M, Mcnicol L, Bellomo R. The haemodynamic effects of intravenous paracetamol (acetaminophen) in healthy volunteers: a double‐blind, randomized, triple crossover trial. Br J Clin Pharmacol. 2016;81(4):605-12.
 
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I struggle to think of any real use for IV Orfimev outside of bowel cases. At the hospital that is more liberal with us using it, I’ve gotten push back from PACU nurses about giving PO Tylenol since it’s “worse” than IV.

Like it’s Tylenol, I’m not expecting an immediate opioid-like response anyway. It’s to cut back the opioid requirements throughout the duration of action of the Tylenol.
 
FiO2@21 said:
I struggle to think of any real use for IV Orfimev outside of bowel cases. At the hospital that is more liberal with us using it, I’ve gotten push back from PACU nurses about giving PO Tylenol since it’s “worse” than IV.

Like it’s Tylenol, I’m not expecting an immediate opioid-like response anyway. It’s to cut back the opioid requirements throughout the duration of action of the Tylenol.
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It's very widely used in Europe. Re PO vs IV i think we use a lot of iv because it's just easier to hang the bag when you want to rather than give it PO at an uncontrolled time on the floor.
 
We did a large unpublished study with thousands in each arm. There was no difference, and we stopped using it except in rare cases. We now give most patients oral Tylenol in preop.

I don’t know if any papers to answer your actual question.
 
pjl said:
We did a large unpublished study with thousands in each arm. There was no difference, and we stopped using it except in rare cases. We now give most patients oral Tylenol in preop.

I don’t know if any papers to answer your actual question.
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What if case goes 10 hours? You redose in OR with IV?
 
We're still in the IV tylenol for everything camp (I don't make the choices). It's in several of our protocols (total joint, bariatric, colon, etc.) but really just a part of the overall ERAS / MMA effort. Our bariatric guys want no pills in pre-op. But at least for my practice, the pre-op nurses are absolutely horrible about giving PO pre-op meds right before we take the pt to the OR (typically famotidine, metoclopramide, etc.). Personally I'd prefer to give it all IV if they're not giving the PO meds on a more timely basis.
 
jwk said:
We're still in the IV tylenol for everything camp (I don't make the choices). It's in several of our protocols (total joint, bariatric, colon, etc.) but really just a part of the overall ERAS / MMA effort. Our bariatric guys want no pills in pre-op. But at least for my practice, the pre-op nurses are absolutely horrible about giving PO pre-op meds right before we take the pt to the OR (typically famotidine, metoclopramide, etc.). Personally I'd prefer to give it all IV if they're not giving the PO meds on a more timely basis.
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Why no pills (what's the reasoning?)
 
For the bariatrics? They don’t want anything solid in the stomach that might mess up the staple lines.
 
About a third of patient will not get to a therapeutic level with single dose 1gm of oral Tylenol because of 1rst pass metabolism.

Everyone gets a therapeutic level with single dose 1gm of IV Tylenol.

Is that worth $8? I don’t know.
 
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academic.oup.com

Randomized trial of oral versus intravenous acetaminophen for postoperative pain control

Purpose. Results of a study comparing pain control outcomes with preoperative oral versus intraoperative i.v. acetaminophen use in adults undergoing total
academic.oup.com academic.oup.com

I.V. acetaminophen was not superior to oral acetaminophen in reducing postoperative nausea and vomiting, time to ambulation, time to first dose of as-needed pain medication, length of PACU stay, or total length of hospital stay.
 
Real
epidural man said:
About a third of patient will not get to a therapeutic level with single dose 1gm of oral Tylenol because of 1rst pass metabolism.

Everyone gets a therapeutic level with single dose 1gm of IV Tylenol.

Is that worth $8? I don’t know.
Click to expand...


Really? $8 per bottle. We were quoted $80-100 a bottle and our hospital did huge volumes in purchasing (40+ ORs not including fluoro procedures or GI). Hospital pharmacy quoted about the same price for suggamadex. Both overutilized and now rarely used, at least by the physicians.
 
BLADEMDA said:
academic.oup.com

Randomized trial of oral versus intravenous acetaminophen for postoperative pain control

Purpose. Results of a study comparing pain control outcomes with preoperative oral versus intraoperative i.v. acetaminophen use in adults undergoing total
academic.oup.com academic.oup.com

I.V. acetaminophen was not superior to oral acetaminophen in reducing postoperative nausea and vomiting, time to ambulation, time to first dose of as-needed pain medication, length of PACU stay, or total length of hospital stay.
Click to expand...

Comparison to rectal tylenol?
 
TheLoneWolf said:
Real


Really? $8 per bottle. We were quoted $80-100 a bottle and our hospital did huge volumes in purchasing (40+ ORs not including fluoro procedures or GI). Hospital pharmacy quoted about the same price for suggamadex. Both overutilized and now rarely used, at least by the physicians.
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Our hospital reports ~$30 a bottle.
 
epidural man said:
About a third of patient will not get to a therapeutic level with single dose 1gm of oral Tylenol because of 1rst pass metabolism.
Click to expand...

Really? Not doubting you but would love to see a source if you have one offhand. I have always read that the bioavailability of acetaminophen is very high, but maybe in certain patients it is lower..?
 
ambiturner said:
$65 here - the fact that $8 and $100 are being quoted as prices for the same product is yet another huge financial problem in our healthcare system
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1.2 to 1.6€/g here!
Screenshot_20200812-232726.png
 
Oral, IV Acetaminophen Equally Effective For Rib Fracture in Elderly

Originally published in our sister publication, Pain Medicine News.
New Orleans—Elderly trauma patients, an ever-increasing population, may experience just as much pain control from oral medication as from IV acetaminophen, according to new research.
“Rib fractures are the most common chest injuries in patients over the age of 65, and pain is the most common symptom after rib fracture. We wanted to see if oral acetaminophen was as effective at controlling pain as IV acetaminophen,” said Andrew C. Antill, MD, a third-year general surgery resident at the University of Tennessee Medical Center, in Knoxville.
To do so, Dr. Antill and his colleagues randomized patients aged 65 years and older with at least one rib fracture to either IV acetaminophen plus oral placebo or IV placebo plus oral acetaminophen. Their primary end point was a mean reduction in pain score at 24 hours; they also evaluated opioid use, ICU and hospital length of stay, use of adjunctive pain control, and development of pneumonia.
Ultimately 138 patients were included in the final analysis, with 63 in the IV drug and oral placebo group, and 75 in the oral acetaminophen and IV placebo group. There was no statistically significant difference in the reduction of pain; at 24 hours, both groups reported a mean pain score reduction of 1 point.
image
There was also no statistically significant difference in the secondary end points. “Oral acetaminophen should be the drug of choice whenever possible due to the high cost of IV acetaminophen,” Dr. Antill said, noting that the cost difference is significant. According to numbers he pulled from the company’s website, a single dose of IV acetaminophen is $180.00 and a single dose of oral acetaminophen is $0.45, a difference of about 400-fold.
Dr. Antill presented his research at the 2020 Southeastern Surgical Congress.
Philip Ramsay, MD, a general and trauma surgeon in Atlanta, affiliated with Wellstar Atlanta Medical Center, called the paper important and relevant given the aging population.
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“We are seeing more elderly trauma patients; we’re trying to decrease the use of opiates; and we are expected to provide excellent health care while decreasing health care costs,” Dr. Ramsay said.
He observed, however, that nearly 35% of patients were excluded due to missed doses of medication and documentation of doses given; he questioned the accuracy of the pain scores.
“We had specific documentation marking every dose of medication and documenting pain scores, so I would think they were pretty accurate,” Dr. Antill said.
One limitation is that the study reached only 30% of required power. It was performed over a three-year period, after which it ran out of funding. “But it was clear by then that there wasn’t a difference,” Dr. Antill said. “There is an opportunity here for further research in a generalized trauma study in a multicenter setting.”
—Monica J. Smith
 
dr doze said:
How good is GI absorption when patients get it a few minutes before going back to the OR, or immediately after surgery in PACU when patients are hurting?
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I tend to think that absorption of PO meds before induction is complete unless you put down an OG and suck out everything. I don’t think pain should have any effect on absorption, even if there is some delayed gastric emptying.
 
Metanalysis on PO vs IV APAP are the worst. Two papers included in each of them with totally different regimens, schedules and outcomes.

there is one paper that showed that IV APAP is superior to PO in the Immediate post-op period and after controlling for various confounders.

personally I have not been convinced about the opposite and I use it almost in every case as long as the nurses did not give a preop PO dose.
 
Lidolover said:
Metanalysis on PO vs IV APAP are the worst. Two papers included in each of them with totally different regimens, schedules and outcomes.

there is one paper that showed that IV APAP is superior to PO in the Immediate post-op period and after controlling for various confounders.

personally I have not been convinced about the opposite and I use it almost in every case as long as the nurses did not give a preop PO dose.
Click to expand...

Along with some lido I'm assuming
 
We switched to almost exclusively oral once the price of IV went way up. Absolutely no way to justify the price difference between the two
 
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